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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 07/14/2023
Date Signed: 07/14/2023 12:23:52 PM


Document Has Been Signed on 07/14/2023 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ELDERVILLAFACILITY NUMBER:
577005638
ADMINISTRATOR:PARAMJIT SINGH SANDHUFACILITY TYPE:
740
ADDRESS:1301 HOMEWOOD DRIVETELEPHONE:
(530) 329-3834
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:6CENSUS: 6DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Paramjit Singh Sandhu, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Required inspection and met with Paramjit Singh Sandhu, Administrator.

LPA conducted a walk-through of the facility with Administrator and observed facility to be clean and well maintained. The facility was a comfortable temperature.

At the time of inspection, there were 5 residents on site and 1 resident was attending a Day Program. There was one care staff and one staff in training. Residents were clean and dressed appropriately. Residents' rooms were furnished per regulation, with personal touches added to make the facility homey. The facility has a visitation area and provides virtual visits and phone calls for family to stay in contact with residents. Residents enjoy internet access via voice control on Smart TV's. The fire extinguisher was last tested and charged on January 5, 2023. The smoke detectors and carbon monoxide detector system were operational, and are tested monthly. The last emergency drill was on June 3, 2023. Water temperature measured 110.3 F.


Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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